Delhi

East Delhi

CC/527/2015

ALOK KR - Complainant(s)

Versus

UIC - Opp.Party(s)

10 May 2019

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer Complaint no.-527/2015

                                                                                                   Date of Institution               29/07/2015

                                                                                                   Order reserved on               20/02/2020

                                                                                                   Date of Order                       25/02/2020

 

In matter of

Mr. Alok Kumar Goyal

s/oShBasantLalGoyal

R/o- 42 New RajdhaniEnclave

Delhi-110092……………………………………...…………………………….Complainant

 

Vs

1-M/s United India Insurance Co. Ltd.

416/1, First Floor, Karkarduma

Opp. Metro Station, KarkardumaDelhi 110092

 

2- M/s M D India Healthcare Services Pvt Ltd, TPA

United India Insurance Co. Ltd.

Plot no. 18/13, WEA, Ground Floor,

Ganga Plaza, Pusa Lane,

Karol Bagh, Delhi 110005 …………………….…………….……………..Respondents

 

Complainant’s Advocate     Mr.AnujKapoor

Opponent’s Advocate        Ms.RichaJindal &MsNanditaSaxena

 

Quorum

Sukhdev SinghPresident

Dr P N TiwariMember

MrsHarpreetKaurMember                                                                                           

 

Order by Dr P N Tiwari  Member

Brief Facts of the case

This complaint has been remanded by the Hon. State Commission Delhi after OP filed Revision Petition no. 117/2015 for setting aside Ex Parte order dated 02/11/2015 under CC no. 527/2015. The order dated 18/03/2016 under RP no. 117/2015 was given to OP to follow further proceedings before the Ld Forum from 21/04/2016 (Ex OPW1/A).

 

Facts –

Complainant took individual mediclaim policy from OP1/ United India Insurance Co. (UIIC) from 31/10/2010 which was renewed regularly up to 30/03/2015 vide policy no. 040100/48/09/07/00004801 to 040100/48/13/97/6191for a sum insured Rs5 lakhs for himself, wife and two children (Ex CW1/1,1A to 1D). It was stated that during policy tenure 2014 to 2015, complainant developed difficulty in breathing and blockage of nose, so took treatment at ENT Super Specialty Hospital at Mumbai and was diagnosed a case of D.N.S. with Tonsillitis(Ex CW1/2) so underwent “Septoplasty with BaloonSinoplastyandand CoblationTonsillectomy(Ex CW1/3) and paid hospital bill of Rs 2,61,500/-(Ex CW1/3A).

 

Complainant lodged claim of Rs2,68,833/- with OP2/TPA. It was also stated that he received an email confirming clearance of amount Rs2,40,000/, but after contacting OP2/TPA, no reply was given. Later the claim was paid after deducting Rs 1,81,500/-and same was not accepted by the complainant on 04/05/2015 (Ex.CW1/4). Thereafter complainant contacted OP2 for deducting his claim, but no reply was received, so he lodged grievances to customer care of OP1. As no reply was received from either OPs, so filed this complaint and claimed deducted amount Rs 1,81,500/- with 24% per annum with Rs 2 lakhs for physical and mental harassmentwith Rs 33000/- as litigation charges.

OP1/UIIC submitted written statement along with related evidences. OP1 submitted facts about OP2 also as their TPA who works as per the guidelines set by IRDA and works under the direction of OP1 with team work. OP1 denied all the allegations of complainant for settling claim by OP2. It was accepted that complainant had individual mediclaim policy from present OP1 and had valid tenure for claim year policy, but policy had detail terms and conditions. It was accepted that the claim of Rs 2,68,833/-was submitted by the complainant and after deducting assisting surgeon’s charges Rs 13,500/-which could not be reimbursed was intimated to complainant. It was also stated that the vague figure of Rs. 1,81,500/- was not existing anywhere, hence paid amount was as per the Claim Settlement Letter exhibiting amount deducted and paid to the complainant.

 

Complainant submitted rejoinder to the written statement of OP and denied all the replies given as wrong and incorrect.  He relied on all facts and evidences in his complaint on records. It was also submitted that even after settling amount for a sum of Rs 2,40,000/, but only Rs 87,337/-were credited in his account, so this proves unfair trade practice and deficiency of OP. Complainant through his own affidavit relied and stressed evidences pertaining to policy copies with terms and conditions, treatment prescriptions, hospital discharge summary with bills, so prayed for passing claim.

 

OP1 submitted their evidences through MrBhuvneshThakkar, Manager with OP1 and stated that TPA/OP2 had processed claim rightly as per the policy terms and conditions and the same had been credited in his account. The detailed claim settlement letter was on record. The deducted sum of amount Rs 13,500/- was not permissible under the said policy terms as assisting surgeon’s charges were not payable, hence, no further liability be imposed contrary to policy terms.

 

Arguments were heard at length and after perusing materials and evidences on record, order was reserved.

We analyzed all the evidences on record and facts of the complaint. By observing the “Claim Payment Statement” under Non Cash Less Claim, (Ex CW1/4), it has been seen that complainant had ailments as DNS (Left) with Rt. Maxillary Sinus with Enlarged Tonsils and the said operation for DNS with Tonsils removal was limited to Rs 80,000/-, where hospital had charged Rs 1,35,600/-as the diagnosed ailments are very chronic ENT problems and claim policy was in fifth year then why excess amount was deducted. As per policy conditions, non-payable charges were deducted by OP2/TPA as not admissible and deduction was justified for Admission charges, Surcharges, Assistant Surgeon’s charges and Coblationwand. Amount Rs 7800/-were rightly deducted for Hospital Anesthesia charges where OT charges were rightly passed for Rs 24,000/-.

We have also seen that OP has submitted evidences on affidavit under para 1 sub point (C) that TPA settled for a sum of Rs 2,40,000/- and deduction was Rs 13,500/-, but we could not find any ‘Slab’ charges for chronic ailments and their operations as shown in claim settlement letterso cannot be accepted. Also OP have not produced any evidence pertaining to charges payable under different heads in a surgical procedure going to be under taken or Slab for surgical procedures. Taking this point in issue, OP is directed to re-consider their claim process again and settle the claim as per policy terms and conditionsin reference to the status of continuity of policy tenure within 45 days and process the claim as per claim policy terms and conditions.There shall be no order to cost. If order is not complied in time essence, complainant is free to proceed accordingly.

 

The first free copy of this order be sent to the parties as per the Section 18(6) of the Consumer Protection Regulations, 2005 (the CPR) and file be consigned to the record room under Sec. 20(1) of the CPR.

 

 

(Dr) P N Tiwari – Member                                         MrsHarpreetKaur- Member                                    

 

Sukhdev Singh - President